An Overview on Prescription Opioids

Opioid drugs are derived from the opium poppy plant or synthesized as substitutes to mimic its effects. Opioids are often referred to as “narcotics,” and they include drugs ranging from the illegal drug heroin to a variety of prescription medications used to treat pain, suppress coughs, induce sleep, or manage diarrhea. Most commonly, prescription opioids are distributed to control acute and chronic pain.

Opioid drugs fill opioid receptors in the brain, which effectively blocks pain sensations and causes dopamine levels to rise. Dopamine is a chemical messenger naturally produced by the brain that enhances pleasure and “feel-good” feelings. Stress, tension, and anxiety are lowered while taking an opioid drug, and several functions of the central nervous system are suppressed. Breathing rates, body temperature, heart rate, and blood pressure are all slowed down with the presence of an opioid drug. These drugs may make a person feel mellow, happy, and drowsy.

Prevalence of Use

Americans make up only about 5 percent of the world’s population; however, people in the United States take 75 percent of the world’s prescription opioids, CNN reports. In 2014, enough prescription opioids were dispensed in the United States for every American adult to have a month-long prescription, as 14 billion opioid pills flooded the market, the Washington Post publishes.

Prescription opioid abuse and overdoses from these drugs has reached staggering levels in the United States, prompting the Centers for Disease Control and Prevention (CDC) to call it an “epidemic.” The CDC reports that 78 people in the United States die from an opioid overdose daily. The National Survey on Drug Use and Health (NSDUH) publishes that in 2014, close to 4.5 million people (aged 12 and older) were using a prescription painkiller for nonmedical purposes currently (meaning that they had used the drug in this manner at some time in the month leading up to the survey).

These drugs may be commonly abused for the mellowing “high” they can produce. They are also considered to be highly addictive drugs, as the American Society of Addiction Medicine (ASAM) reports that nearly 2 million American adults (those over the age of 11) battled an addiction involving a prescription opioid drug in 2014.

Common Prescription Opioid Drugs

The Drug Enforcement Administration (DEA) classifies prescription opioids in varying levels of control and regulation depending on their medical use versus their safety, abuse potential, and likelihood of inducing drug dependence. The control status ranges from Schedule I, which includes drugs like heroin that have no approved medical use in the United States and are thus considered illegal, to Schedule V, which includes drugs that have a lower abuse and dependence potential and are considered to have legitimate and approved medicinal properties. Some of the more common prescription opioids, according to their DEA drug Schedule, are highlighted below:

Schedule II Controlled Substances

Hydrocodone combination products (e.g., Vicodin, Lorcet, Lortab): These products contain fewer than 15 milligrams of hydrocodone and are combined with other over-the-counter analgesics, such as acetaminophen, ibuprofen, or aspirin. Within the United States, hydrocodone is the most prescribed opioid, and it is regularly diverted and abused, the DEA Coming in syrups, tablets, or capsules, hydrocodone products are prescribed for acute pain and as cough suppressants. When abused, they may be swallowed, snorted, smoked, or injected. The United States consumes almost 100 percent (99 percent to be exact) of the world’s hydrocodone, the American Society of Interventional Pain Physicians (ASIPP) reports.

Fentanyl (e.g., Sublimaze, Duragesic, Actiq, Fentora): Used for breakthrough, chronic, and acute pain treatment, fentanyl is 100 times more potent than morphine, the DEA It is distributed in patch form, as a “lollipop” (an oral transmucosal lozenge), in injectable form, or as an effervescent buccal tablet. It may be used to “cut” heroin or be added to it for a more intense and dangerous “high.” Fentanyl patches are often frozen, cut up, sucked on, or the gel may be scraped off and then smoked or injected. Fentanyl rapidly crosses the blood-brain barrier and is one of the more potent and powerful prescription opioid drugs on the market.

Hydromorphone (e.g., Dilaudid, Exalgo): Designed to treat moderate to severe pain, these products are formulated in vials for multiple doses, suppositories, tablets, and injectable forms. Hydrocodone’s immediate-release format may be a common target for abuse and diversion, especially within rural and suburban communities, the DEA

Oxycodone (e.g., OxyContin, Roxicet, Percocet): A semisynthetic pain reliever, oxycodone comes in both extended-release and immediate-release tablets. Abuse is common, as the drug is often inhaled or injected, the DEA

Methadone (e.g., Dolophine, Diskets, Methadose): A synthetic opioid that is long-acting and manufactured in wafer, liquid, or pill forms, methadone products are distributed by federally regulated opioid dependence treatment and/or detoxification facilities to aid in withdrawal from other short-acting opioid drugs, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports. Methadone is often a part of an opioid dependence treatment plan, although it too carries risks for diversion and abuse.

Meperidine (e.g., Demerol, Mepergan): According to The Journal of Pediatric Pharmacology and Therapeutics (JPPT), meperidine was the first opioid to be synthesized. For a time, it was considered favorable when treating pain and as an antispasmodic for its quick onset and relatively short duration of action. It is also highly addictive and can produce a powerful euphoric “high.” Currently, the DEA publishes that these products are mostly used licitly before or after surgery or medical procedures or in obstetrics as a pain reliever in injectable forms, tablets, or syrups. Illicit formulations of meperidine analogues are manufactured in clandestine laboratories, which can produce a neurotoxic by-product (MPTP) that can cause irreversible brain damage similar to Parkinson’s disease.

Morphine (e.g., MS-Contin, Roxanol, Oramorph-SR, Kadian, RMS, MSiR): According to the DEA, morphine is one of the most effective pain medications on the market. It is available in both immediate- and extended-release tablets, suppositories, oral solutions, and injectable forms. Morphine is derived directly from the seedpod of the opium poppy plant from which heroin can then be illegally produced, the National Highway Traffic Safety Association (NHTSA) publishes.

Codeine: Also derived from the opium poppy plant, codeine is often combined with other medications and distributed as both a pain medication and a cough suppressant (antitussive). The US National Library of Medicine (NLM) reports that these opiate products are available in liquid, tablet, or capsule forms, generally to be taken every 4-6 hours as needed.

Schedule III Controlled Substances

Codeine combination products (e.g., Tylenol with codeine – Tylenol #3, etc.): This includes products containing fewer than 90 milligrams of codeine per dosage that are then combined with another over-the-counter analgesic, such as acetaminophen (Tylenol) or aspirin, per the FDA. Often made into cough and cold medications, these combination products come in a variety of formulations.

Buprenorphine (e.g., Suboxone, Zubsolv, Bunavail): This is a partial opioid agonist used to treat opioid dependence, as it partially fills opioid receptors in the brain, thus staving off opioid withdrawal side effects. Buprenorphine products are approved to be prescribed out of a physician’s office for the treatment of opioid dependence as a substitution for other short-acting opioid drugs like heroin, the National Institute on Drug Abuse (NIDA) reports. Buprenorphine has a plateau effect after a certain amount is taken, meaning that it shouldn’t produce the same “high” as other opioid drugs do. Buprenorphine is often combined with naloxone, an opioid antagonist, during opioid dependence treatment to promote compliance and continued abstinence, as it works to block additional opioid drugs from working on the opioid receptors and instead precipitates withdrawal if abused. Buprenorphine products come in sublingual tablets, transmucosal products, and sublingual filmstrips.

Schedule IV Controlled Substances

Tramadol (e.g., ConZip, Ultram, Ryzolt, Rybix ODT): This is an analgesic prescribed for moderate or chronic pain. These products are distributed in extended-release or immediate-release options in tablet, capsule, or liquid suspension formulations, Mayo Clinic

Risks of Abusing Opioids

Opioid drugs will have varying effects, depending on which drug was taken, the dosage, and the method taken. Injecting, snorting, or smoking these drugs sends them directly into the bloodstream and across the blood-brain barrier, increasing the risk for these opioids to overwhelm the brain and body. Bypassing a drug’s extended-release format by altering them (like by chewing them or crushing them to snort, smoke, or inject them) also increases the potential dangers and odds for a toxic overdose, as does mixing opioid drugs with alcohol or other central nervous system depressants like benzodiazepine drugs.

The Drug Abuse Warning Network (DAWN) reports that almost a half-million Americans sought emergency department (ED) treatment for the abuse of an opioid drug in 2011, more than three-quarters of which were for adverse reactions involving narcotic pain relievers. When someone uses an opioid drug without a prescription, either recreationally to get “high” or as a method of self-medication, it is considered drug abuse.

One of the biggest dangers of abusing an opiate drug is the potential for a life-threatening overdose. In 2014, nearly 50,000 people died from a drug overdose in the United States, and more than half of these fatalities involved an opioid drug, the CDC reports. When someone overdoses on an opiate, they struggle to breathe and may stop breathing altogether. Pupils may become very small; the pulse may weaken; the skin may be cold to the touch and blue in color; and blood pressure may drop. Chest pain, mental confusion, and drowsiness are also signs of an opioid overdose, which is a medical emergency. With swift administration of an opioid antagonist like Narcan (naloxone), and further medical treatment, an opioid overdose may be reversed.

When someone abuses an opioid drug, the risk for overdose is always present. In addition to this potential hazard, opioid drugs have many other possible side effects as well. Opioids can reduce a person’s inhibitions, alter moods, and make it less likely that someone will make sound decisions. Individuals may participate in risky activities or engage in sexual encounters that they may never have considered prior to taking the drug. Accidents and injuries may be common side effects of opioid abuse, as these drugs can impair a person’s coordination, motor and muscle control, and reflexes. Mood swings and behavioral changes as well as weight loss and sleep disturbances are also typical in those regularly using opioid drugs for nonmedical purposes. These drugs can also create tolerance rather quickly, meaning that a person will need to up the dosage to keep feeling their effects.

Opioid drugs are considered to be highly addictive as physical dependence is formed with regular use or abuse. Both licit use and abuse can cause drug dependence. The CDC reevaluated opioid prescription practices in the United States in 2016, particularly those used for the treatment of chronic pain, finding many more negative side effects than benefits when these drugs are taken on a long-term basis, the Journal of the American Medical Association (JAMA) publishes.

When someone takes one of these drugs regularly, the brain’s reward and pleasure center as well as the regions responsible for decision-making, short-term memory, and impulse control are disrupted. Chemical pathways are physically changed as dopamine levels flood the brain when opioids are present and drop significantly when the drugs wear off. Levels of some of the impacted naturally occurring brain chemicals become unbalanced as they may now rely on opioid drugs in order to remain at normal levels in the brain. Withdrawal symptoms when opioid drugs then wear off, or are not active in the bloodstream, can be intense both physically and emotionally.

Treating Opioid Dependence and Addiction

Opioid drugs can be effective on pain when used as directed under direct medical supervision. Generally, they are intended for the short-term relief of symptoms and not for chronic use due to the ease at which dependence is formed. Once opioid dependence is created, medical detox is often considered the optimal method for helping the body to process the drugs out of the system.

During medical detox, substitution opioid medications, like buprenorphine and methadone, can be useful in keeping opioid receptors full in the brain and mitigating withdrawal symptoms. During opioid withdrawal, many of the autonomic functions that were suppressed by the opioid drugs will rebound. Heart rate, blood pressure, respiration rates, and body temperature may all spike. Tremors, dilated pupils, sweating, chills, nausea, vomiting, diarrhea, chest pain, stomach cramps, insomnia, yawning, runny nose, tearing up, and muscle, bone, and joint pain are all side effects of opioid withdrawal. The process generally sets in 12-30 hours after the last dose of an opioid drug, NLM states. Emotional side effects like anxiety, depression, irritability, agitation, restlessness, mental “fogginess,” difficulties concentrating, and trouble feeling happy are additional symptoms of opioid withdrawal.

In addition to opioid substitution medications, other pharmaceutical methods may be helpful in treating these specific side effects of withdrawal during detox. Supportive measures, including encouragement, mental health support, and the provision of a safe and secure environment, are vital parts of a medical detox program. Detox generally lasts 3-7 days on average and should be followed with an opioid addiction treatment program that is personalized for the individual working toward recovery.

New England Treatment Options

Within New England, there are several different types of treatment programs for individuals and families to choose from. Private programs may offer more services and be more comprehensive in nature while public opioid dependence treatment offerings are open to everyone and usually funded by state, federal, or local resources. Each individual state and locality will have specific regulations regarding addiction treatment, licensing, and accreditation.

Treatment services typically include behavioral therapies with group and individual sessions, as well as counseling, mental health support, stress management and skills training, and medications when needed. Mental illness and addiction often occur simultaneously, as SAMHSA reports that close to 8 million Americans (aged 18 and older) are suffering from co-occurring disorders involving both mental health and addiction. Addiction and mental health are often treated in an integrated fashion and commonly considered behavioral health concerns. SAMHSA’s behavioral health locator tool is a great resource for finding local treatment options in both the addiction and mental health services field.

Treatment options for opioid dependence in New England include:

Medical detox: aid in processing the toxins out of the body in a 24/7 medically monitored environment, with the use of pharmaceutical and supportive measures

Residential treatment: a program where individuals remain onsite in a highly structured environment that provides therapeutic and counseling services as well as supportive, pharmacological, and adjunct therapy tools

Partial hospitalization: a comprehensive and short-term treatment program that serves as a middle ground between intensive outpatient and residential treatment options

Intensive outpatient services: similar to residential programs with counseling, therapy, and life skills training sessions during the day, but individuals go home at night

Outpatient programs: can be more flexible, with sessions and meetings scheduled around other existing obligations

Transitional services: sober living homes and other programs that provide support after residential treatment to ensure that healthy habits are fully formed before returning to everyday life at home

Support and relapse prevention programs: aftercare services, peer support, and 12-Step programs to help maintain recovery and prevent relapse